Table.

Key challenges at community, health system and policy level and recommended strategies for a national programme on prevention and control of snakebite in India

Key challenges	Recommended strategies
At the community level
• Lack of knowledge on venomous and non-venomous snakes, appropriate preventive measures6. • Use of harmful methods (tourniquet, incision on bite area, etc.) as a first aid, superstitions, chanting of mantras, use of unproven herbal medicines6. • Health-seeking behaviour-prefer to visit faith healers, tantriks, Ozas, Sarpa Chikitsa, etc.6,15.	• Active engagement of forest department and herpetologists for identification and mapping of circulating venomous and non-venomous snakes in a specific geographical region. • Community empowerment and active engagement of community leaders, religious leaders and school teachers to increase awareness on prevention, first aid and early transport of snakebite patients to the nearest health facility. • Adequate training must be provided to the traditional healers to identify red flags in snakebite victims that require urgent referrals to healthcare facilities. Traditional healers along with the key community persons like the Sarpanch (head of the village), the school teachers, gram sevak (government representative in the village) and village elders form an important influencing group. Awareness programmes conducted by them would be better accepted.
At the health system level
• No attention paid to snakebite in the medical curriculum. • No exposure to snakebite treatment during internship. • MOs in State health services have no experience of snakebite management9,10. • No uniform protocol followed for snakebite treatment9,10. • MOs at PHC, CHC do not have confidence of ASV administration, fear of anaphylaxis6,9,10. • Lack of life support skills15.	• To include snakebite management in the curriculum of training institutions of the State public health departments. • Periodic training of MOs in PHCs, CHCs as per the latest national snakebite management protocol. • Empowerment of frontline healthcare providers (ASHA, ANM, MPW) on prevention, first aid and timely referral for management of SBE. • Mandatory short-term training of medical graduates during internship and as a part of the induction training on joining as MOs in the State health services. • Training of nurses on treatment of snakebite with emphasis on ASV administration.
• Irrational use of the intradermal ASV test leading to wastage of precious ASV33.	• ASV manufactures in India (public and private sector) should immediately revise the ASV insert and remove the recommendation on ASV intradermal skin testing.
• ASV intradermal skin test recommended by ASV manufacturers34.	• To ensure safe, adequate supply of ASVs and other emergency medicines required for snakebite management.
At the policy level
• Huge gap between number of snakebite deaths reported from direct surveys and hospital-based data15. • Snakebite is not a notifiable disease.	• Making the disease notifiable would further help to identify hotspots for SBE and directed attempts to reduce the incidence and mortality in these hotspots can be made. • Online data entry of snakebite cases into a dedicated snakebite portal.
• The existing guidelines of MJPJAY+PMJAY provide Rs. 50,000 for snakebite patients requiring ventilator support. • Patients who do not need ventilator support are excluded from getting the benefit of MJPJAY + PMJAY leading to extensive financial burden.	• Revision of policy to include all patients of SBE for free of cost treatment in all healthcare facilities (public and private hospitals). • Financial assistance for deaths due to SBE.
• SBE disproportionately affects the rural populations, migrant workers and people engaged in agriculture32.	• Directed efforts in states with high proportion of vulnerable population and high caseload will ensure effective administration and would help in cutting the cost of implementation in the whole country. • States with high proportion of vulnerable population but low caseload should be empowered with robust surveillance systems to counter underreporting.
• Long-term complications occur in around 15 per cent of survivors (musculoskeletal deformities, amputations, visual impairment, chronic kidney disease, paralysis and disability and psychological health consequences)9,32	• Psychological counselling of family members of snakebite victims. • Rehabilitation centre for management of snakebite related complications. • Referral linkages to be established between PHCs, CHCs and tertiary care hospitals for transfer of critical patients who require higher-level management.

MOs, medical officers; MJPJAY, Mahatma Jyotiba Phule Jan Arogya Yojana; PMJAY, Prime Minister Jan Arogya Yojana; PHCs, primary health centres; CHCs, community health centres; ASHA, Accredited Social Health Activist; ANM, auxiliary nurse midwife; MPW, multipurpose worker; ASV, anti-snake venom; SBE, snakebite envenomation